Cycle 1
Health 2025-07-31 · Fire 2025-07-31
10 health deficiencies
Top issue: Administration (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
North Miami, FL
Villa Maria Nursing Center
2-star overall rating with 1-star inspections with abuse icon flag with $184,075 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1050 Ne 125th Street, North Miami, FL
(305) 891-8850
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
212
Certified beds
Average residents
190
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1970-05-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.64
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.44
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.77
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,037
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9996
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
4.03
Baseline 6.68% · Performance 6.63% · Measure score 4.03 · Achievement 4.03 · Improvement 0
Total nurse turnover
7.58
Baseline 40.22% · Performance 32.70% · Measure score 7.58 · Achievement 7.58 · Improvement 4.39
Adjusted total nurse staffing
2.28
Baseline 3.85 hours · Performance 3.73 hours · Measure score 2.28 · Achievement 2.28 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.18% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 4.92% · Lower 95% interval 6.83% |
| Discharge to community | 63.41% |
50.57%
12.8 pts better
|
Better than the National Rate · Eligible stays 47 · Observed rate 53.19% · Lower 95% interval 50.69% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.65% |
95.27%
3.4 pts better
|
Numerator 73 · Denominator 74 |
| Falls with major injury | 1.35% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 74 |
| Discharge self-care score | 37.5% |
53.69%
16.2 pts worse
|
Numerator 18 · Denominator 48 |
| Discharge mobility score | 29.17% |
50.94%
21.8 pts worse
|
Numerator 14 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 74 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.63% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 6.25% · Lower 95% interval 3.06% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 236 |
| Staff flu vaccination coverage | 99.3% |
42%
57.3 pts better
|
Numerator 285 · Denominator 287 |
| Discharge function score | 35.42% |
56.45%
21 pts worse
|
Numerator 17 · Denominator 48 |
| Transfer of health information to provider | 85.19% |
95.95%
10.8 pts worse
|
Numerator 23 · Denominator 27 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
5.9%
0.3 pts better
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 7.8% · Q3 6.1% · Q4 3.4% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.6% |
15.7%
10.1 pts better
|
19.6%
14 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 7.0% · Q3 4.8% · Q4 5.4% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.9% |
9.8%
3.9 pts better
|
16.7%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 6.2% · Q3 8.0% · Q4 3.1% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.6% |
11.7%
8.1 pts better
|
16.3%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 7.0% · Q3 1.7% · Q4 3.9% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.2% |
9.8%
5.6 pts better
|
14.9%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 6.1% · Q3 0.9% · Q4 2.7% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
0.4%
0.3 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.5% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.1% |
12.5%
10.4 pts better
|
19.8%
17.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.1% · Q3 1.3% · Q4 1.3% · 4Q avg 2.1% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
5.1%
3.1 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.6% · Q3 0.8% · Q4 1.7% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.5% |
9.3%
6.8 pts better
|
12.0%
9.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.5% · Observed 2.4% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.8% · Q3 1.2% · Q4 2.6% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.7% |
26.2%
6.5 pts worse
|
23.9%
8.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.7% · Observed 36.6% · Expected 26.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-15 · Fire 2024-03-15
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-12-01 · Fire 2022-12-01
7 health deficiencies
Top issue: Administration (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-07-31
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-08-31
L · Immediate jeopardy
2024-03-15
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-04-21
L · Immediate jeopardy
2024-03-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-21
L · Immediate jeopardy
2024-03-15
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-04-21
F · Potential for more than minimal harm
2024-03-15
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-04-21
F · Potential for more than minimal harm
2024-03-15
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2024-04-21
F · Potential for more than minimal harm
2024-03-15
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-04-21
F · Potential for more than minimal harm
2022-12-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-01
E · Potential for more than minimal harm
2022-12-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-01
D · Potential for more than minimal harm
2022-12-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-01
D · Potential for more than minimal harm
2022-12-01
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-01-01
Inspection history
Recent health citations
J · Immediate jeopardy
2025-09-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-10-10
J · Immediate jeopardy
2025-09-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-09-05
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-09-05
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-07-31
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-31
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-31
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-31
L · Immediate jeopardy
2024-03-15
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-04-21
F · Potential for more than minimal harm
2024-03-15
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-04-21
D · Potential for more than minimal harm
2024-03-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-21
D · Potential for more than minimal harm
2024-03-15
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-04-21
D · Potential for more than minimal harm
2024-03-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-21
D · Potential for more than minimal harm
2024-03-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-21
E · Potential for more than minimal harm
2022-12-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-01
E · Potential for more than minimal harm
2022-12-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-01
D · Potential for more than minimal harm
2022-12-01
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-01-01
D · Potential for more than minimal harm
2022-12-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-01-01
D · Potential for more than minimal harm
2022-12-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-01
C · Minimal harm
2022-12-01
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-01-01
C · Minimal harm
2022-12-01
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2023-01-01
Penalties and ownership
What sits behind the stars
$65,615
2025-09-05
Fine
Fine · fine $65,615
Fine
$118,460
2024-03-15
Fine
Fine · fine $118,460
Fine
Ownership
Archdiocese Of Miami Inc
5% Or Greater Indirect Ownership Interest · Organization
Villa Maria Nursing & Rehabilitation Center
5% Or Greater Direct Ownership Interest · Organization
Frick, Mary
Corporate Officer · Individual
Johnson, Nathaniel
Operational/Managerial Control · Individual
Moghaddam, Hamidreza
Operational/Managerial Control · Individual
Wilson, Laura
Operational/Managerial Control · Individual
Nearby options
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4-star overall rating with 3-star inspections with $11,187 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Biscayne Health And Rehabilitation Center
North Miami, FL
5-star overall rating with 4-star inspections with 4 recent health deficiencies
#3
North Dade Nursing And Rehabilitation Center
North Miami, FL
1-star overall rating with 1-star inspections with $142,068 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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